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FW: Clinical Pharmacy Specialist in Cardiology: What's in a Name?

A couple of weeks ago, I attended a summit on team-based care at the American College of Cardiology. Very few of my fellow attendees were aware of the training expected of pharmacists practicing in a cardiology setting, and I was encouraged to write an entry on the topic. In the meantime, editorials like this make it clear that the public remains equally unaware of even the minimum expectations for pharmacists. Although the training and expectations of clinical pharmacists practicing in cardiology are rapidly evolving, the following information is a summary of the current paradigm, which is also depicted in the graphic below (click to enlarge):

Undergraduate Education

Pharmacists complete a minimum of two years of undergraduate education prior to being accepted to pharmacy school. Although the required coursework differs by school, many programs expect up to three years of undergraduate coursework in areas similar to what is required for those entering medicine and other health professions (e.g., biology, physical and organic chemistry, calculus, anatomy and physiology, etc.). An undergraduate degree gradually became an expectation of medical school applicants as a consequence of market demand and a similar trend is occurring in pharmacy. Currently, the number of pharmacy school applicants with undergraduate degrees is approaching 70%.

Most schools also require that applicants complete the Pharmacy College Admissions Test (PCAT), which is analogous to the examination for medical school applicants (Medical College Admissions Test or MCAT) and covers the areas of reading, writing, verbal ability, biology, chemistry, and quantitative analysis.

Pharmacy is a doctorate-level degree program that focuses on the safe and effective use of medication therapy. At some schools, the curriculum begins with the pathophysiologic basis of disease and then transitions to therapeutics. Others design the curriculum in a modular fashion, where the pathophysiologic and therapeutic aspects of each disease state are covered at one time. To complement the core therapeutics curriculum, students also complete coursework in public health, law, management, pharmacoeconomics, and pharmacogenomics, among other subjects.

Professional Skills Development

Concurrent to the didactic curriculum are skills-based courses that focus on the fundamentals of professional pharmacy practice, including the preparation, delivery, and dispensing of drugs; patient assessment, including physical examination; and patient communication. Many schools use objective structured clinical examinations (OSCEs) to assess student competence in these areas and a growing number use simulations and actual patients as part of skills-based courses.

Practice Experiences

During the first three years of the curriculum, students complete introductory pharmacy practice experiences (IPPEs), which altogether constitute 5% of the curriculum. In IPPEs, students integrate their knowledge and skills into practice, often through interactions with patients. At a minimum, IPPEs are completed in both community and hospital/health-system settings.

Advanced pharmacy practice experience (APPEs, often called “rotations”) are the capstone of the pharmacy curriculum and constitute 25% of total coursework. In APPEs, students are assigned, often in blocks of 4-6 weeks, to a variety of practice settings, including acute and critical care (i.e., general practice as well as specialties like cardiology and infectious diseases), ambulatory care (i.e., clinic-based management of chronic diseases), community pharmacy, managed care, and administration. In APPEs, students serve as extenders of care by performing activities such as medication histories, medication reconciliation, and patient education. Literature evaluation is also emphasized as students learn how to integrate evidence-based medicine into practice. Finally, in concert with their preceptor, students also gain experience in the optimization of medication therapy (e.g., for safety, efficacy, and cost).

Approximately one-third of graduates pursue postgraduate residency training, as it is quickly becoming an expectation for positions involving direct patient care in ambulatory and acute care settings. The process is highly competitive; in 2014, less than two-thirds of applicants entering the match process successfully obtained residency positions. Whereas training programs in many professions consist of on-the-job training, pharmacy residency programs must meet rigorous educational standards in order to be accredited nationally. Postgraduate Year 1 (PGY1) residencies may be completed in community, hospital/health system, or managed care settings. Many graduates then pursue a Postgraduate Year 2 (PGY2) residency in a specialty area such as cardiology, infectious diseases, oncology, or solid organ transplantation. Most cardiology pharmacists complete PGY2 training in cardiology, although some complete residencies in internal medicine or critical care.

Some also pursue research fellowships before or after residency training.

Board Certification & Other Credentials

Many pharmacists practicing in direct patient care roles obtain board certification from the Board of Pharmacy Specialties (BPS). To become a Board Certified Pharmacotherapy Specialist (BCPS), a pharmacist must practice for three years (with the majority of their experience being in the management of pharmacotherapy) or complete a PGY1 residency, and then achieve a passing score on the BCPS board examination. Board certification is also available in other practice areas, including nutrition support, oncology, critical care, and pediatrics. In addition to board certification, most cardiology specialists pursue Added Qualifications in Cardiology (AQ Cardiology), which requires submission of a professional portfolio for peer review, demonstrating significant contributions in the area of cardiovascular medicine through practice, teaching, and research. Recently a study demonstrated that institutions employing pharmacists with the BCPS-AQ Cardiology designation performed better on national process of care measures.

Recently the profession has collectively advocated that pharmacists be recognized by the Centers for Medicare and Medicaid Services (CMS) as health care providers, whose services should be paid for in a fashion similar to other providers (either as fee-for-service in the current model or as part of the team-based approach emphasized in value-based care models). Incumbent to obtaining these privileges is the burden of proof that pharmacists possess the knowledge and skills necessary for providing valuable clinical services as well as a willingness to accept accountability for medication-related health outcomes. Overall, clinical pharmacists in the area of cardiology have a doctorate-level education and have completed years of postgraduate residency training; many have obtained board certification and/or additional credentials. Although they are often considered as being integral members of the health care team by their colleagues in other health professions, their practice remains limited by a lack of recognition among payers. To truly move forward, the latter has to change.

To follow efforts being made by pharmacists to achieve provider status, click here.